Provider Demographics
NPI:1073666020
Name:PEACOCK, BETSY A (CRNA)
Entity Type:Individual
Prefix:MS
First Name:BETSY
Middle Name:A
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 QUALITY DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-9494
Mailing Address - Country:US
Mailing Address - Phone:707-624-4207
Mailing Address - Fax:
Practice Address - Street 1:1 QUALITY DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-9494
Practice Address - Country:US
Practice Address - Phone:707-624-4207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-20
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA421990367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ13179Medicare UPIN